Contextual factors influencing patients' experiences of acute deterioration and medical emergency team (MET) encounter: A grounded theory study.

AIM: This paper explores the personal, social and structural factors that influence patients' experiences of acute deterioration and medical emergency team (MET) encounter. BACKGROUND: Patient experience is recognized as a means of assessing healthcare delivery with a positive experience being linked to high-quality healthcare, improved patient safety and reduced length of stay. The experience of acute deterioration is unique, extensive and complex. However, little is known about this experience from the patient's perspective. DESIGN: Constructivist grounded theory, informed by Kathy Charmaz, was used to explore the personal, social and structural factors that influence patients' experiences of acute deterioration and MET encounter. METHODS: Using a semi-structured interview guide, in-depth individual interviews were conducted with 27 patients from three healthcare services in Victoria, Australia. Data were collected over a 12-month period from 2018 to 2019. Interview data were analysed using grounded theory processes. FINDINGS: Contextual factors exert a powerful influence on patients' experiences of acute deterioration and MET encounter. The most significant factors identified include patients' expectations and illness perception, relationship with healthcare professionals during MET call and past experiences of acute illness. The expectations and perceptions patients had about their disease can condition their overall experience. Healthcare professional-patient interactions can significantly impact quality of care, patient experience and recovery. Patients' experiences of illness and healthcare can impact a person's future health-seeking behaviour and health status. CONCLUSION: Patients' actions and processes about their experiences of acute deterioration and MET encounter are the result of the complex interface of contextual factors. IMPACT: The findings from this study have highlighted the need for revised protocols for screening and management of patients who experience acute deterioration.

Quaternary Charge-Transfer Complex Enables Photoenzymatic Intermolecular Hydroalkylation of Olefins.

Intermolecular C-C bond-forming reactions are underdeveloped transformations in the field of biocatalysis. Here we report a photoenzymatic intermolecular hydroalkylation of olefins catalyzed by flavin-dependent 'ene'-reductases. Radical initiation occurs via photoexcitation of a rare high-order enzyme-templated charge-transfer complex that forms between an alkene, α-chloroamide, and flavin hydroquinone. This unique mechanism ensures that radical formation only occurs when both substrates are present within the protein active site. This active site can control the radical terminating hydrogen atom transfer, enabling the synthesis of enantioenriched γ-stereogenic amides. This work highlights the potential for photoenzymatic catalysis to enable new biocatalytic transformations via previously unknown electron transfer mechanisms.

Locating "gold standard" evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review.

AIMS AND OBJECTIVES: To extract, examine and report the highest available levels of evidence from healthcare disciplines in the use of simulation-based education as substitution for clinical placement in prelicensure programmes. BACKGROUND: Simulation is widely employed across prelicensure health professional education to create safe, realistic clinical learning experiences for students. Whether simulation can be employed to substitute for actual clinical placement, and if so, in what proportion, replacement ratio and duration, is unclear. METHODS: A systematic review and quality appraisal of primary studies related to prelicensure students in all health disciplines, guided by the PRISMA checklist. RESULTS: Ten primary studies were included, representing 2,370 students from three health disciplines in four countries. Nine studies were experimental and quasi-experimental and methodological quality was assessed as moderate to high with good to very good inter-rater agreement. Direct substitution of simulation for clinical practice ranged from 5% to 50%. With one exception, replacement ratios were 1:1 and duration of replacement ranged from 21 hr-2 years. Levels of evaluation included measures of reaction, knowledge and behaviour transfer; no negative outcomes were reported. We appraised practicalities for design of substitution, design limitations and knowledge transfer to accreditation standards for prelicensure programmes. CONCLUSIONS: This review synthesised highest levels and quality of available evidence for substitution of simulation for clinical placement in health professional education. Included studies were heterogenous in simulation interventions (proportion, ratio and duration) and in the evaluation of outcomes. Future studies should incorporate standardised simulation curricula, widen the health professions represented and strengthen experimental designs. RELEVANCE TO CLINICAL PRACTICE: Current evidence for clinical educational preparation does not appear to be translated into programme accreditation standards governing clinical practice experience for prelicensure programmes in relevant jurisdictions. Overall, a stronger evidence base is necessary to inform future curricula and policy development, to strengthen clinical practice in health.

The impact of web-based and face-to-face simulation on patient deterioration and patient safety: protocol for a multi-site multi-method design.

BACKGROUND: There are international concerns in relation to the management of patient deterioration which has led to a body of evidence known as the 'failure to rescue' literature. Nursing staff are known to miss cues of deterioration and often fail to call for assistance. Medical Emergency Teams (Rapid Response Teams) do improve the management of acutely deteriorating patients, but first responders need the requisite skills to impact on patient safety. METHODS/DESIGN: In this study we aim to address these issues in a mixed methods interventional trial with the objective of measuring and comparing the cost and clinical impact of face-to-face and web-based simulation programs on the management of patient deterioration and related patient outcomes. The education programs, known as 'FIRST(2)ACT', have been found to have an impact on education and will be tested in four hospitals in the State of Victoria, Australia. Nursing staff will be trained in primary (the first 8 min) responses to emergencies in two medical wards using a face-to-face approach and in two medical wards using a web-based version FIRST(2)ACTWeb. The impact of these interventions will be determined through quantitative and qualitative approaches, cost analyses and patient notes review (time series analyses) to measure quality of care and patient outcomes. DISCUSSION: In this 18 month study it is hypothesised that both simulation programs will improve the detection and management of deteriorating patients but that the web-based program will have lower total costs. The study will also add to our overall understanding of the utility of simulation approaches in the preparation of nurses working in hospital wards. (ACTRN12616000468426, retrospectively registered 8.4.2016).

Leadership and teamwork in medical emergencies: performance of nursing students and registered nurses in simulated patient scenarios.

AIMS AND OBJECTIVES: To examine nursing students' and registered nurses' teamwork skills whilst managing simulated deteriorating patients. BACKGROUND: Studies continue to show the lack of timely recognition of patient deterioration. Management of deteriorating patients can be influenced by education and experience. DESIGN: Mixed methods study conducted in two universities and a rural hospital in Victoria, and one university in Queensland, Australia. METHODS: Three simulation scenarios (chest pain, hypovolaemic shock and respiratory distress) were completed in teams of three by 97 nursing students and 44 registered nurses, equating to a total of 32 student and 15 registered nurse teams. Data were obtained from (1) Objective Structured Clinical Examination rating to assess performance; (2) Team Emergency Assessment Measure scores to assess teamwork; (3) simulation video footage; (4) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken. RESULTS: Objective structured clinical examination performance was similar across registered nurses and students (mean 54% and 49%); however, Team Emergency Assessment Measure scores differed significantly between the two groups (57% vs 38%, t = 6·841, p < 0·01). In both groups, there was a correlation between technical (Objective Structured Clinical Examination) and nontechnical (Team Emergency Assessment Measure) scores for the respiratory distress scenario (student teams: r = 0·530, p = 0·004, registered nurse teams r = 0·903, p < 0·01) and hypovolaemia scenario (student teams: r = 0·534, p = 0·02, registered nurse teams: r = 0·535, p = 0·049). Themes generated from the analysis of the combined quantitative and qualitative data were as follows: (1) leadership and followership behaviours; (2) help-seeking behaviours; (3) reliance on previous experience; (4) fixation on a single detail; and (5) team support. CONCLUSIONS: There is scope to improve leadership, team work and task management skills for registered nurses and nursing students. Simulation appears to be beneficial in enabling less experienced staff to assess their teamwork skills. RELEVANCE TO CLINICAL PRACTICE: There is a need to encourage less experienced staff to become leaders and for all staff to develop improved teamwork skills for medical emergencies.

E-simulation: preregistration nursing students' evaluation of an online patient deterioration program.

This study explores preregistration nursing students' views of a Web-based simulation program: FIRST ACTWeb (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends-Web). The multimedia program incorporating three videoed scenarios portrayed by a standardized patient (human actor) aims to improve students' recognition and management of hospital patient deterioration. Participants were 367 final-year nursing students from three universities who completed an online evaluation survey and 19 students from two universities who attended one of five focus groups. Two researchers conducted a thematic analysis of the transcribed narratives. Three core themes identified were as follows: "ease of program use," "experience of e-Simulation," and "satisfaction with the learning experience." The Web-based clinical learning environment was endorsed as functional, feasible, and easy to use and was reported to have high fidelity and realism. Feedback in both focus groups and surveys showed high satisfaction with the learning experience. Overall, evaluation suggested that the Web-based simulation program successfully integrated elements essential for blended learning. Although Web-based educational applications are resource intensive to develop, positive appraisal of program quality, plus program accessibility and repeatability, appears to provide important educational benefits. Further research is needed to determine the transferability of these learning experiences into real-world practice.

Foxo3a drives proliferation in anaplastic thyroid carcinoma through transcriptional regulation of cyclin A1: a paradigm shift that impacts current therapeutic strategies.

The Forkhead transcription factor, FoxO3a, is a known suppressor of primary tumor growth through transcriptional regulation of key genes regulating cell cycle arrest and apoptosis. In many types of cancer, in response to growth factor signaling, FoxO3a is phosphorylated by Akt, resulting in its exclusion from the nucleus. Here we show that FoxO3a remains nuclear in anaplastic thyroid carcinoma (ATC). This correlates with lack of Akt phosphorylation at serine473 in ATC cell lines and tissues of ATC patients, providing a potential explanation for nuclear FoxO3a. Mechanistically, nuclear FoxO3a promotes cell cycle progression by transcriptional upregulation of cyclin A1, promoting proliferation of human ATC cells. Silencing FoxO3a with a reverse genetics approach leads to downregulation of CCNA1 mRNA and protein. These combined data suggest an entirely novel function for FoxO3a in ATC promotion by enhancing cell cycle progression and tumor growth through transcriptional upregulation of cyclin A1. This is clinically relevant since we detected highly elevated CCNA1 mRNA and protein levels in tumor tissues of ATC patients. Our data indicate therapeutic inactivation of FoxO3a may lead to attenuation of tumor expansion in ATC. This new paradigm also suggests caution in relation to current dogma focused upon reactivation of FoxO3a as a therapeutic strategy against cancers harboring active PI3-K and Akt signaling pathways.

Bachelor of Science in Nursing students' perceptions of being a nurse: A scoping review.

BACKGROUND: High attrition rates in new graduate nurses maybe attributed to unrealistic perceptions of being a nurse. It is therefore important to identify nursing students' perceptions and the factors that influence them. AIM: The present study was conducted to identify and describe the literature relating to nursing students' perceptions of being a nurse. Research questions guiding the review were: (1) What are nursing students' perceptions of nursing? (2) What factors influence nursing students' perceptions of nursing? METHOD: A scoping literature review was conducted between the years 2008 and March 2022 to capture nursing student perceptions from multiple countries, and year levels of study to note the changes in perceptions overtime. The data sources consisted of five electronic data bases; CINAHL, Medline, PsychINFO, Scopus, and Web of Science and search engine Google Scholar revealed 39 relevant sources. A scoping review methodology informed by the Joanna Briggs Institute and a published Scoping Review Checklist guided this review. An inductive thematic analysis identified five key themes. RESULTS: Key themes: Attributes and characteristics of nurses; Nursing as a profession; Skills required for nursing; Gender perceptions; and Influence of time and previous health work experience. Findings provide insight for future research to ensure the adequacy of curricula experiences in preparing new graduates for having realistic perceptions for practice. CONCLUSION: For nursing students to be prepared for the role of a nurse they must have realistic perceptions of what it means to be a nurse. Whilst it is evident that perceptions can be influenced by a variety of sources, this review highlights a lack of research pertaining to perceptions related to the physical, emotional, and social effects on an individual from being a nurse.

Exploring Hospital Inpatients' Awareness of Their Falls Risk: A Qualitative Exploratory Study.

Patient falls in hospital may lead to physical, psychological, social and financial impacts. Understanding patients' perceptions of their fall risk will help to direct fall prevention strategies and understand patient behaviours. The aim of this study was to explore the perceptions and experiences that influence a patient's understanding of their fall risk in regional Australian hospitals. Semi-structured, individual interviews were conducted in wards across three Australian hospitals. Participants were aged 40 years and over, able to communicate in English and were mobile prior to hospital admission. Participants were excluded from the study if they returned a Standardised Mini-Mental State Examination (SMMSE) score of less than 18 when assessed by the researcher. A total of 18 participants with an average age of 69.8 years (SD ± 12.7, range 41 to 84 years) from three regional Victorian hospitals were interviewed for this study. Data were analysed using a reflexive thematic analysis identifying three major themes; (1) Environment (extrinsic) (2) Individual (intrinsic), and (3) Outcomes, as well as eight minor themes. Participants recognised the hazardous nature of a hospital and their personal responsibilities in staying safe. Falls education needs to be consistently delivered, with the focus on empowering the patient to help them adjust to changes in their clinical condition, whether temporary or permanent.

p38 MAP kinase plays a functional role in UVB-induced mouse skin carcinogenesis.

UVB irradiation of epidermal keratinocytes results in the activation of the p38 mitogen-activated protein kinase (MAPK) pathway and subsequently activator protein-1 (AP-1) transcription factor activation and cyclooxygenase-2 (COX-2) expression. AP-1 and COX-2 have been shown to play functional roles in UVB-induced mouse skin carcinogenesis. In this study, the experimental approach was to express a dominant negative p38α MAPK (p38DN) in the epidermis of SKH-1 hairless mice and assess UVB-induced AP-1 activation, COX-2 expression, and the skin carcinogenesis response in these mice compared to wild-type littermates. We observed a significant inhibition of UVB-induced AP-1 activation and COX-2 expression in p38DN transgenic mice, leading to a significant reduction of UVB-induced tumor number and growth compared to wild-type littermates in a chronic UVB skin carcinogenesis model. A potential mechanism for this reduction in tumor number and growth rate is an inhibition of chronic epidermal proliferation, observed as reduced Ki-67 staining in p38DN mice compared to wild-type. Although we detected no difference in chronic apoptotic rates between transgenic and nontransgenic mice, analysis of acutely irradiated mice demonstrated that expression of the p38DN transgene significantly inhibited UVB-induced apoptosis of keratinocytes. These results counter the concerns that inhibition of p38 MAPK in a chronic situation could compromise the ability of the skin to eliminate potentially tumorigenic cells. Our data indicate that p38 MAPK is a good target for pharmacological intervention for UV-induced skin cancer in patients with sun damaged skin, and suggest that inhibition of p38 signaling reduces skin carcinogenesis by inhibiting COX-2 expression and proliferation of UVB-irradiated cells.

Simulation-based learning in nurse education: systematic review.

AIM: This paper is a report of a review of the quantitative evidence for medium to high fidelity simulation using manikins in nursing, in comparison to other educational strategies. BACKGROUND: Human simulation is an educational process that can replicate clinical practices in a safe environment. Although endorsed in nursing curricula, its effectiveness is largely unknown. REVIEW METHODS: A systematic review of quantitative studies published between 1999 and January 2009 was undertaken using the following databases: CINAHL Plus, ERIC, Embase, Medline, SCOPUS, ProQuest and ProQuest Dissertation and Theses Database. The primary search terms were 'simulation' and 'human simulation'. Reference lists from relevant papers and the websites of relevant nursing organizations were also searched. The quality of the included studies was appraised using the Critical Appraisal Skills Programme criteria. RESULTS: Twelve studies were included in the review. These used experimental or quasi-experimental designs. All reported simulation as a valid teaching/learning strategy. Six of the studies showed additional gains in knowledge, critical thinking ability, satisfaction or confidence compared with a control group (range 7-11%). The validity and reliability of the studies varied due to differences in design and assessment methods. CONCLUSION: Medium and/or high fidelity simulation using manikins is an effective teaching and learning method when best practice guidelines are adhered to. Simulation may have some advantage over other teaching methods, depending on the context, topic and method. Further exploration is needed to determine the effect of team size on learning and to develop a universal method of outcome measurement.

Patients' experiences of acute deterioration: A scoping review.

BACKGROUND: Patient experience is recognised as a means of assessing healthcare delivery with organisations in many countries now gathering patient experience or satisfaction data. It is well documented that the benefits of improving a patients' experience include increased satisfaction, reduced length of stay, improved patient outcomes and reduction of costs. The experience of acute clinical deterioration is unique, extensive and complex as well as being a difficult experience for all involved. However, little is known about this experience from the patient's perspective. AIM: To explore what is known about the experiences of acute deterioration from the perspective of the patient. DESIGN: A scoping review of international, peer-reviewed research studies and grey literature published between the years of 2000 and 2018. This review was guided by the three-step search strategy recommended by the Joanna Briggs Institute (JBI). DATA SOURCES: A range of databases were searched, including CINAHL, Medline, Health Source, Joanna Briggs Institute, PsycINFO, Embase via Ovid, Cochrane library, Ovid Emcare, Scopus as well as grey literature, reference lists and the search engine Google Scholar. REVIEW METHODS: Joanna Briggs Institute (JBI) scoping review framework was utilised to identify patients' experiences of acute deterioration. Ten databases were searched, and 249 articles were retrieved. After screening the titles and abstracts, 102 articles were assessed in full text for eligibility, and finally 23 articles were further analysed and synthesised using inductive thematic analysis. RESULTS: 19 qualitative studies, three quantitative and one mixed methods study met the inclusion criteria. Seven key themes emerged related to patients' experience of acute deterioration: (1) transformation of perception: memories of factual events; (2) psychological transformation: emotional distress and well-being; (3) physiological transformation: physical distress; (4) facing death; (5) the severity of acute deterioration: from the perspective of the patient; (6) relationship with healthcare professionals and the clinical environment; and (7) the value of relationships: the support of family and friends. CONCLUSIONS: Participants had considerable recall of their experiences and hospital admissions. The themes highlight the important issues patients face during their own acute physiological deterioration. This review has highlighted that further research is needed to specifically explore the patients' experience of acute deterioration and the emergency management they receive, for example from a hospital's rapid response team (RRT) or medical emergency team (MET).

Type III transforming growth factor-beta (TGF-beta) receptor mediates apoptosis in renal cell carcinoma independent of the canonical TGF-beta signaling pathway.

PURPOSE: Alterations in transforming growth factor-beta (TGF-beta) signaling occur early during malignant transformation of renal epithelial cells and are associated with loss of type III TGF-beta receptor (TbetaRIII) expression. We evaluated the role of TbetaRIII in mediation of apoptosis using in vitro cell culture and in vivo animal models of clear cell renal cell carcinoma. EXPERIMENTAL DESIGN: TbetaR3 expression was manipulated with adenoviral gene vector delivery system in vitro and in vivo. Induction of apoptosis and signaling through the Smad and mitogen-activated protein kinase (MAPK) pathways were examined at various time points after infection. To study viral oncolysis in vivo, human renal cell carcinoma cells were implanted s.c. in the flanks of nude mice and treated with intratumoral injections of adenovirus. RESULTS: Restoring TbetaRIII expression in clear cell renal cell carcinoma resulted in a marked induction of apoptosis using in vitro cell culture and in vivo animal models. The expression of the cytoplasmic domain, but not the extracellular domain, of TbetaRIII mimicked the induction of apoptosis by full-length TbetaRIII in cell culture and the growth inhibition of tumors in athymic nude mice. TbetaRIII-associated apoptosis was not dependent on signaling through the canonical TGF-beta/Smad pathway but was mediated through p38 MAPK. CONCLUSION: These findings indicate a novel mechanistic antitumor function for TbetaRIII and further support its role as an important tumor suppressor in clear cell renal cell carcinoma.

Photoexcitation of flavoenzymes enables a stereoselective radical cyclization.

Photoexcitation is a common strategy for initiating radical reactions in chemical synthesis. We found that photoexcitation of flavin-dependent "ene"-reductases changes their catalytic function, enabling these enzymes to promote an asymmetric radical cyclization. This reactivity enables the construction of five-, six-, seven-, and eight-membered lactams with stereochemical preference conferred by the enzyme active site. After formation of a prochiral radical, the enzyme guides the delivery of a hydrogen atom from flavin-a challenging feat for small-molecule chemical reagents. The initial electron transfer occurs through direct excitation of an electron donor-acceptor complex that forms between the substrate and the reduced flavin cofactor within the enzyme active site. Photoexcitation of promiscuous flavoenzymes has thus furnished a previously unknown biocatalytic reaction.

Expression of the type III TGF-beta receptor is negatively regulated by TGF-beta.

The type III transforming growth factor-beta receptor (TbetaRIII or betaglycan) is a ubiquitously expressed transforming growth factor-beta (TGF-beta) superfamily coreceptor with essential roles in embryonic development. Recent studies have defined a role for TbetaRIII in the pathogenesis of human cancers, with frequent loss of TbetaRIII expression at the message and protein level. Mechanisms for the loss of TbetaRIII expression remain to be fully defined. Advanced human cancers often have elevated circulating levels of TGF-beta1. Here, we define a specific role for TGF-beta1 in negatively regulating TbetaRIII at the message level in breast and ovarian cancer models. TGF-beta1 decreased TbetaRIII message and protein levels in ovarian (Ovca420) and breast cancer (MDA-MB-231) cell lines in both a dose- and time-dependent manner. TGF-beta1-mediated TbetaRIII repression is mediated by the type I TGF-beta receptor/Smad2/3 pathway as the activin receptor-like kinase 5 (ALK5) inhibitor, SB431542, abrogated this effect, while the expression of constitutively active ALK5 was sufficient to repress TbetaRIII expression. Mechanistically, TGF-beta1 does not affect TbetaRIII messenger RNA (mRNA) stability, but instead directly regulates the TbetaRIII promoter. We define alternative promoters for the TGFBR3 gene, a distal and proximal promoter. Although both promoters are active, only the proximal promoter was responsive and negatively regulated by TGF-beta1 and constitutively active ALK5. Taken together, these studies define TGF-beta1-mediated downregulation of TbetaRIII mRNA expression through effects on the ALK5/Smad2/3 pathway on the TGFBR3 gene proximal promoter as a potential mechanism for decreased TbetaRIII expression in human cancers.

Rating teams' non-technical skills in the emergency department: A qualitative study of nurses' experience.

INTRODUCTION: Non-technical skills (NTS) teamwork training can enhance clinicians' understanding of roles and improve communication. We evaluated a quality improvement project rating teams' NTS performance to determine the value of formal rating and debriefing processes. METHODS: In two Australian emergency departments the NTS of resuscitation teams were rated by senior nurses and medical staff. Key measures were leadership, teamwork, and task management using a valid instrument: Team Emergency Assessment Measure (TEAM™). Emergency nurses were asked to attend a focus group from which key themes around the quality improvement process were identified. RESULTS: Main themes were: 'Team composition' (allocation of resuscitation team roles), 'Resuscitation leadership' (including both nursing and medical leadership roles) and 'TEAM™ ratings promote reflective practice' (providing staff a platform to discuss team effectiveness). Objective ratings were seen as enabling staff to provide feedback to other team members. Reflection on practice and debriefing were thought to improve communication, help define roles and responsibilities, and clarify leadership roles. CONCLUSION: Use of a non-technical skills rating scheme such as TEAM™ after team-based clinical resuscitation events was seen by emergency department nurses as feasible and a useful process for examining and improving multi-disciplinary practice, while improving team performance.

Catalytic promiscuity enabled by photoredox catalysis in nicotinamide-dependent oxidoreductases.

Strategies that provide enzymes with the ability to catalyse non-natural reactions are of considerable synthetic value. Photoredox catalysis has proved adept at expanding the synthetic repertoire of existing catalytic platforms, yet, in the realm of biocatalysis it has primarily been used for cofactor regeneration. Here we show that photoredox catalysts can be used to enable new catalytic function in nicotinamide-dependent enzymes. Under visible-light irradiation, xanthene-based photocatalysts enable a double-bond reductase to catalyse an enantioselective deacetoxylation. Mechanistic experiments support the intermediacy of an α-acyl radical, formed after the elimination of acetate. Isotopic labelling experiments support nicotinamide as the source of the hydrogen atom. Preliminary calculations and mechanistic experiments suggest that binding to the protein attenuates the reduction potential of the starting material, an important feature for localizing radical formation to the enzyme active site. The generality of this approach is highlighted with the radical dehalogenation of α-bromoamides catalysed by ketoreductases with Eosin Y as a photocatalyst.

The educational impact of web-based and face-to-face patient deterioration simulation programs: An interventional trial.

BACKGROUND: There are international concerns relating to the management of patient deterioration. The "failure to rescue" literature identifies that nursing staff miss cues of deterioration and often fail to call for assistance. Simulation-based educational approaches may improve nurses' recognition and management of patient deterioration. OBJECTIVES: To investigate the educational impact of the First2Act web-based (WB) and face-to-face (F2F) simulation programs. DESIGN & SETTING: A mixed methods interventional cohort trial with nursing staff from four Australian hospitals. PARTICIPANTS: Nursing staff working in four public and private hospital medical wards in the State of Victoria. METHODS: In 2016, ward nursing staff (n = 74) from a public and private hospital completed three F2F laboratory-based team simulations with a patient actor in teams of three. 56 nursing staff from another public and private hospital individually completed a three-scenario WB simulation program (First2ActWeb) [A 91% participation rate]. Validated tools were used to measure knowledge (multi-choice questionnaire), competence (check-list of actions) and confidence (self-rated) before and after the intervention. RESULTS: Both WB and F2F participants' knowledge, competence and confidence increased significantly after training (p ≤0.001). Skill performance for the WB group increased significantly from 61% to 74% (p ≤ 0.05) and correlated significantly with post-test knowledge (p = 0.014). No change was seen in the F2F groups' performance scores. Course evaluations were positive with median ratings of 4/5 (WB) and 5/5 (F2F). The F2F program received significantly more positive evaluations than the WB program (p < 0.05), particularly with regard to quality of feedback. CONCLUSION: WB and F2F simulation are effective education strategies with both programs demonstrating positive learning outcomes. WB programs increase ease of access to training whilst F2F enable the development of tactile hands on skills and teamwork. A combined blended learning education strategy is recommended to enhance competence and patient safety.

The value of simulation-based learning in pre-licensure nurse education: A state-of-the-art review and meta-analysis.

Simulation modalities are numerous in nursing education, with a need to reveal their range and impact. We reviewed current evidence for effectiveness of medium to high fidelity simulation as an education mode in pre-licensure/pre-registration nurse education. A state-of-the-art review and meta-analyses was conducted based on a systematic search of publications in English between 2010 and 2015. Of 72 included studies, 43 were quantitative primary studies (mainly quasi-experimental designs), 13 were qualitative studies and 16 were reviews of literature. Forty of 43 primary studies reported benefits to student learning, and student satisfaction was high. Simulation programs provided multi-modal ways of learning. A meta-analysis (8 studies, n = 652 participants) identified that simulation programs significantly improved clinical knowledge from baseline. The weighted mean increase was 5.0 points (CI: 3.25-6.82) on a knowledge measure. Other objectively rated measures (eg, trained observers with checklists) were few. Reported subjective measures such as confidence and satisfaction when used alone have a strong potential for results bias. Studies presented valid empirical evidence, but larger studies are required. Simulation programs in pre-licensure nursing curricula demonstrate innovation and excellence. The programs should be shared across the discipline to facilitate development of multimodal learning for both pre-licensure and postgraduate nurses.